Understanding trends and variation in paediatric fracture management in England

Sarah Lucas

03 July 2024

Background (continued)

Epidemiology of paediatric fractures

One hospital in Ireland calculated a paediatric fracture incidence rate of approximately 29 fractures/1,000/year1. The most common fracture was distal radial/buckle fractures (27.2%), followed by distal humerus /supracondylar fracture (13.9%), ankle fractures (9.2%), phalanx fractures (8.3%), and radial/ulnar metaphysis fractures (5.7%). It is suggested the incidence rate will depend on the social emphasis on encouraging physical activity1.

Between 2012–2019, 368,120 children under 18 were admitted to English NHS hospitals with a fracture; 256,008 (69.5%) were upper limb and 85,737 (23.3%) were lower limb fractures2. The annual incidence of upper limb fractures was highest in children aged 5–9 (348.3 per 100 000 children).

Paediatric fracture management

British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement3.

The FORCE study found in children with a torus fracture of the distal radius there was no difference in outcomes between those who were offered of a bandage and immediate discharge (as per UK National Institute for Health and Clinical Excellence recommendations) and those receiving current treatment of rigid immobilisation and follow-up4.

One study in Scotland found that uncomplicated paediatric clavicle fractures can be managed without x-rays in the ED as they do not influence ultimate management or add valuable information to clinicians’ assessment5.


  1. Baig MN. (2017) A Review of Epidemiological Distribution of Different Types of Fractures in Paediatric Age. Cureus. 28;9(8):e1624
  2. Marson BA et al. (2021) Trends in hospital admissions for childhood fractures in England. BMJ Paediatr Open. 10;5(1):e001187
  3. Modifiable Templates for Management of Common Fractures. https://www.bscos.org.uk/public/resources.
  4. Perry DC et al. (2022). Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet; 400(10345):39-47
  5. Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304.

Background (continued)

Manipulation of paediatric fractures

A GIRFT report on Paediatric Trauma and Orthopaedic Surgery found that over 250 weeks of operating time a year had been dedicated to manipulation of the forearm and wrist between 2016 and 20191. A significant proportion of these displaced or angulated wrist fractures could have been manipulated and cast in the emergency department rather than being admitted and treated in the operating theatre. The GIRFT report found significant variation between trusts in the number of manipulating being performed in theatre; if this number was reduced to the level in trusts with well-developed ED manipulation protocols, there would be an 80% (equivalent this number could be reduced by 80% (to 57 weeks or less).

Due to pressures on hospitals from the COVID-19 pandemic the British Orthopaedic Association developed guidelines for the early management of distal forearm fractures in children. A study conducted at one trust found following the implementation of these guidelines resulted in 86% of distal forearm fractures in children were manipulated in the ED, an increase from 32% prior to the COVID pandemic2. This saved approximately 63 hours of theatre time in the six-month study period.

The GIRFT report highlighted reluctance to perform procedures in the emergency department because of worries about breach times, a lack of space/facilities to perform sedation and a lack of familiarity with techniques1.




  1. Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
  2. Fink BE etal (2023) Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines. Cureus. 15(7):e41325.

Aims


  1. Update and add to the information in the literature on the epidemiology/incidence rate of various paediatric fractures (toe, clavicle, wrist and elbow) in England.

  2. Understand the trends in management of these fracture types over time, e.g. have changes in guidance during COVID-19 changed the trends in management of fractures in Emergency departments.

  3. Investigate the variation in management of these fracture types between Trusts, and the potential activity and cost savings if there was more widespread conservative management, such as reducing unnecessary follow-ups appointments and manipulation in the Emergency Department rather than in theatre.

Characteristics of the cohort

 

Clavicle
(N=85,059)

Elbow
(N=120,928)

Forearm
(N=456,246)

Tibia/Fibula
(N=75,464)

Toe
(N=80,592)

Overall
(N=818,289)

Sex

  Female

26,136 (30.7%)

55,208 (45.7%)

177,392 (38.9%)

30,505 (40.4%)

32,922 (40.9%)

322,163 (39.4%)

  Male

58,730 (69.0%)

65,450 (54.1%)

277,866 (60.9%)

44,786 (59.3%)

47,543 (59.0%)

494,375 (60.4%)

  Missing/Unknown

193 (0.2%)

270 (0.2%)

988 (0.2%)

173 (0.2%)

127 (0.2%)

1,751 (0.2%)

Age

  0-4 yrs

23,105 (27.2%)

30,400 (25.1%)

51,688 (11.3%)

34,193 (45.3%)

3,917 (4.9%)

143,303 (17.5%)

  5-10 yrs

25,808 (30.3%)

59,043 (48.8%)

198,389 (43.5%)

16,173 (21.4%)

28,950 (35.9%)

328,363 (40.1%)

  11-16 yrs

36,146 (42.5%)

31,485 (26.0%)

206,169 (45.2%)

25,098 (33.3%)

47,725 (59.2%)

346,623 (42.4%)

Ethnicity

  Asian or Asian British

4,433 (5.2%)

10,582 (8.8%)

27,603 (6.1%)

5,062 (6.7%)

5,039 (6.3%)

52,719 (6.4%)

  Black or Black British

1,965 (2.3%)

2,550 (2.1%)

9,466 (2.1%)

2,397 (3.2%)

2,025 (2.5%)

18,403 (2.2%)

  Mixed

2,641 (3.1%)

4,185 (3.5%)

13,760 (3.0%)

2,838 (3.8%)

2,531 (3.1%)

25,955 (3.2%)

  Other Ethnic Groups

2,332 (2.7%)

3,434 (2.8%)

12,242 (2.7%)

2,389 (3.2%)

2,048 (2.5%)

22,445 (2.7%)

  White

65,421 (76.9%)

88,962 (73.6%)

350,757 (76.9%)

55,718 (73.8%)

61,305 (76.1%)

622,163 (76.0%)

  Missing/Unknown

8,267 (9.7%)

11,215 (9.3%)

42,418 (9.3%)

7,060 (9.4%)

7,644 (9.5%)

76,604 (9.4%)

IMD Quintiles

  1

18,703 (22.0%)

30,817 (25.5%)

107,598 (23.6%)

19,165 (25.4%)

18,683 (23.2%)

194,966 (23.8%)

  2

15,823 (18.6%)

23,746 (19.6%)

87,574 (19.2%)

14,901 (19.7%)

15,428 (19.1%)

157,472 (19.2%)

  3

16,088 (18.9%)

22,121 (18.3%)

84,499 (18.5%)

13,628 (18.1%)

15,022 (18.6%)

151,358 (18.5%)

  4

16,518 (19.4%)

21,594 (17.9%)

84,812 (18.6%)

13,537 (17.9%)

15,050 (18.7%)

151,511 (18.5%)

  5

17,053 (20.0%)

21,428 (17.7%)

87,439 (19.2%)

13,489 (17.9%)

15,756 (19.6%)

155,165 (19.0%)

  Missing/Outside England

874 (1.0%)

1,222 (1.0%)

4,324 (0.9%)

744 (1.0%)

653 (0.8%)

7,817 (1.0%)

Emergency Dept type

  Major Emergency Dept

67,905 (79.8%)

96,895 (80.1%)

346,775 (76.0%)

63,707 (84.4%)

53,154 (66.0%)

628,436 (76.8%)

  Urgent Treatment Centre/Walk in centre

17,145 (20.2%)

24,025 (19.9%)

109,425 (24.0%)

11,739 (15.6%)

27,437 (34.0%)

189,771 (23.2%)

  Mono-specialty Emergency Dept

0 (0%)

0 (0%)

1 (0.0%)

2 (0.0%)

0 (0%)

3 (0.0%)

  Same Day Emergency Care

9 (0.0%)

8 (0.0%)

45 (0.0%)

16 (0.0%)

1 (0.0%)

79 (0.0%)

Day of ED attendance

  Weekday

59,139 (69.5%)

86,777 (71.8%)

335,199 (73.5%)

53,123 (70.4%)

59,826 (74.2%)

594,064 (72.6%)

  Weekend

25,920 (30.5%)

34,151 (28.2%)

121,047 (26.5%)

22,341 (29.6%)

20,766 (25.8%)

224,225 (27.4%)

Time of ED attendance

   Daytime 7am to 7pm

72,991 (85.8%)

101,388 (83.8%)

395,392 (86.7%)

64,579 (85.6%)

70,489 (87.5%)

704,839 (86.1%)

  Nighttime 7pm to 7am

12,068 (14.2%)

19,540 (16.2%)

60,854 (13.3%)

10,885 (14.4%)

10,103 (12.5%)

113,450 (13.9%)

Year of ED attendance

  2018/19

11,763 (13.8%)

16,982 (14.0%)

60,326 (13.2%)

10,092 (13.4%)

10,794 (13.4%)

109,957 (13.4%)

  2019/20

14,562 (17.1%)

21,099 (17.4%)

76,552 (16.8%)

12,714 (16.8%)

14,956 (18.6%)

139,883 (17.1%)

  2020/21

11,611 (13.7%)

16,944 (14.0%)

64,097 (14.0%)

10,721 (14.2%)

9,967 (12.4%)

113,340 (13.9%)

  2021/22

16,739 (19.7%)

21,952 (18.2%)

93,942 (20.6%)

14,192 (18.8%)

15,032 (18.7%)

161,857 (19.8%)

  2022/23

15,121 (17.8%)

21,855 (18.1%)

81,667 (17.9%)

13,739 (18.2%)

14,598 (18.1%)

146,980 (18.0%)

  2023/24

15,263 (17.9%)

22,096 (18.3%)

79,662 (17.5%)

14,006 (18.6%)

15,245 (18.9%)

146,272 (17.9%)

Fracture incidence rates


Annual fracture incidence rates per 100,000 (2023/2024)

Type

Female
0-4 yrs

Female
11-16 yrs

Female
5-10 yrs

Male
0-4 yrs

Male
11-16 yrs

Male
5-10 yrs

Total

Clavicle

130.4

62.3

76.8

131.4

249.7

153.7

135.6

Elbow

171.8

94.5

283.4

174.1

173.4

270.7

196.5

Forearm

273.9

487.5

837.6

277.2

1,269.5

867.1

708.1

Tibia/Fibula

173.6

70.5

71.8

212.6

170.9

76.3

124.3

Toe

17.0

159.9

125.3

25.7

280.7

142.4

135.5


Forearm/wrist fractures are the most common followed by elbow fractures.

Incidence rate by age/sex group


Tibia/Fibula fractures are most common in those aged 0-4 years

Elbow fractures are most common in those aged 5-10 years

In the 11-16 year old age group all fracture types are more common in males compared to females, with males aged 11-16 yrs ols having the highest incidence of clavicle, forearm and toe fractures.

Incidence of upper limb fractures by ICB (2023/2024)

Incidence of lower limb fractures by ICB (2023/2024)


For all fracture types the incidence rates are high in the Cornwall and Isles of Scilly ICB area. There are also generally high rates across several fracture types in the Gloucester and Hereford and Worcestershire ICB areas.

The fracture incidence rate is generally lowest is the South East of England, particularly in the London area.

Table of incidence rates per 100,000 by ICB (2023/2024)

ICB

Clavicle

Elbow

Forearm

Tibia/Fibula

Toe

Total

NHS Cornwall and the Isles of Scilly Integrated Care Board

215.5

328.8

1,273.2

188.5

218.6

444.9

NHS Herefordshire and Worcestershire Integrated Care Board

190.9

290.2

1,106.6

134.0

244.4

393.2

NHS Gloucestershire Integrated Care Board

214.7

189.2

1,126.4

182.7

193.4

381.3

NHS Shropshire, Telford and Wrekin Integrated Care Board

188.1

265.8

994.0

131.3

211.2

358.1

NHS Dorset Integrated Care Board

183.0

263.5

988.6

138.2

192.9

353.2

NHS Staffordshire and Stoke-on-Trent Integrated Care Board

163.0

225.7

952.9

154.7

218.3

342.9

NHS Somerset Integrated Care Board

189.5

261.7

966.8

133.7

162.6

342.8

NHS South Yorkshire Integrated Care Board

169.7

270.7

934.3

150.1

178.2

340.6

NHS Lincolnshire Integrated Care Board

168.2

237.8

919.8

150.0

210.2

337.2

NHS Norfolk and Waveney Integrated Care Board

191.5

252.2

910.2

158.7

157.0

333.9

NHS Sussex Integrated Care Board

166.0

249.4

926.8

130.7

169.3

328.4

NHS Humber and North Yorkshire Integrated Care Board

195.7

221.6

867.0

139.3

171.1

318.9

NHS Devon Integrated Care Board

164.6

235.2

881.1

140.8

136.6

311.7

NHS Northamptonshire Integrated Care Board

172.9

227.6

805.3

127.2

169.8

300.6

NHS Nottingham and Nottinghamshire Integrated Care Board

150.4

239.1

802.6

152.2

156.7

300.2

NHS North East and North Cumbria Integrated Care Board

135.3

219.6

792.3

140.5

177.6

293.1

NHS Derby and Derbyshire Integrated Care Board

150.9

212.2

788.4

153.4

142.4

289.5

NHS Mid and South Essex Integrated Care Board

141.6

221.0

775.2

163.7

139.5

288.2

NHS Birmingham and Solihull Integrated Care Board

135.7

246.5

762.9

125.3

156.9

285.5

NHS Hampshire and Isle of Wight Integrated Care Board

138.8

229.9

780.1

142.3

129.4

284.1

NHS Black Country Integrated Care Board

131.6

259.8

767.4

123.9

124.2

281.4

NHS Greater Manchester Integrated Care Board

133.3

188.9

789.4

109.7

158.6

276.0

NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board

139.2

205.6

762.5

131.0

135.9

274.8

NHS Coventry and Warwickshire Integrated Care Board

153.8

188.9

744.1

133.8

141.2

272.4

NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board

131.4

235.6

728.4

105.9

151.2

270.5

NHS Cheshire and Merseyside Integrated Care Board

148.1

211.0

732.1

129.7

131.2

270.4

NHS West Yorkshire Integrated Care Board

161.2

203.0

703.4

137.5

136.1

268.2

NHS Lancashire and South Cumbria Integrated Care Board

135.9

190.8

696.3

141.6

134.1

259.7

NHS Leicester, Leicestershire and Rutland Integrated Care Board

131.5

201.7

641.2

156.4

121.7

250.5

NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board

123.8

218.5

642.5

172.0

90.3

249.4

NHS Surrey Heartlands Integrated Care Board

141.1

171.9

646.4

136.5

143.9

248.0

NHS Hertfordshire and West Essex Integrated Care Board

124.2

169.6

622.8

110.7

123.3

230.1

NHS Cambridgeshire and Peterborough Integrated Care Board

123.6

162.5

595.3

83.7

109.6

214.9

NHS Suffolk and North East Essex Integrated Care Board

129.1

145.3

551.5

100.9

116.6

208.7

NHS North Central London Integrated Care Board

96.0

141.5

520.4

105.2

104.5

193.5

NHS South West London Integrated Care Board

92.2

100.0

449.5

110.7

98.1

170.1

NHS Kent and Medway Integrated Care Board

87.4

102.7

487.7

62.2

107.6

169.5

NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board

96.3

134.4

444.0

82.5

59.0

163.2

NHS North West London Integrated Care Board

78.8

119.0

423.0

86.3

62.5

153.9

NHS Frimley Integrated Care Board

77.5

118.4

394.2

77.5

66.1

146.7

NHS South East London Integrated Care Board

63.9

99.9

322.4

78.5

65.6

126.0

NHS North East London Integrated Care Board

62.8

124.1

306.6

79.1

53.6

125.2

Most common fracture types (2023/2024)


SNOMED description

Number

Percentage

Closed fracture of radius (disorder)

Forearm

48,080

32.9

Elbow fracture - closed (disorder)

Elbow

18,582

12.7

Closed fracture of radius AND ulna (disorder)

Forearm

17,508

12.0

Closed fracture of clavicle

Clavicle

15,254

10.4

Closed fracture of phalanx of foot (disorder)

Toe

15,233

10.4

Closed fracture of tibia (disorder)

Tibia/Fibula

8,554

5.8

Closed fracture scaphoid, waist, transverse (disorder)

Forearm

7,614

5.2

Closed fracture of ulna (disorder)

Forearm

4,338

3.0

Closed supracondylar fracture of humerus (disorder)

Elbow

3,396

2.3

Closed fracture of fibula (disorder)

Tibia/Fibula

3,272

2.2

Closed fracture of tibia AND fibula (disorder)

Tibia/Fibula

2,144

1.5

Closed fracture of carpal bone (disorder)

Forearm

1,998

1.4

Closed Monteggia's fracture (disorder)

Elbow

103

0.1

Closed Galeazzi fracture (disorder)

Forearm

64

0.0

Closed fracture of distal end of radius (disorder)

Forearm

23

0.0

Closed fracture of lower end of radius AND ulna (disorder)

Forearm

11

0.0

Only showing those fracture types recorded 10 or more times


The majority of fractures are recorded within the emergency care dataset under just a few snomed codes.

Percentage of fractures with a follow-up appointment


There is a trend towards a reduction in the proportion of emergency department attendances for upper limb fractures where a follow-up appointment is given.

Proportion of face-to-face vs virtual follow-up appointments


As a result of the COVID-19 pandemic the proportion of follow up appointments conducted face to face has fallen significantly.

Percentage of fractures manipulated in the ED


The percentage of forearm fractures manipulated in the Emergency Department has increased over the last 6 yrs, with a large increase seen during the COVID-19 pandemic. There is also a noticeable seasonal trend with a greater percentage of fractures manipulated in the emergency department during the summer months.

There also an increase in the percentage of tibia/fibula fractures manipulated in the emergency department, but little change in the percentage of other fracture types.

Percentage of fractures manipulated in theatre


The percentage of forearm fractures manipulated in theatre has decreased significantly over the last 6 yrs, with a greater percentage of fractures manipulated in theatre during the summer months.

There is also a decrease in the percentage of tibia/fibula fractures manipulated in theatre.

Proportion of fractures manipulated in ED vs theatre

Over the last 6 years the proportion of manipulations in theatre compared to the emergency department has decreased; currently over half of all manipulations are performed in the emergency department.

Percentage of fractures referred for physiotherapy


The percentage of emergency department attendances for fractures that result in a referral/outpatient attendance for physiotherapy are low, and appears generally unchanged over the last 6 years.

Percentage of fractures with a X-ray recorded in the ED


The majority of fractures of all types are x-rayed in the emergency department, although the percentage of toe fractures x-rayed is slightly lower.

There appears to be a very small reduction in the percentage of upper limb and toe fractures x-rayed in more recent years.

Calculating proportions by trust


Includes only trusts in our dataset that had a total of number of attendances for fractures of over 120 for the 2022/23; this excluded mainly independent providers, and a small number of trusts that likely have small numbers due to alternative paediatric provision locally, e.g. Royal Liverpool which is close to Alder Hey.

Upper limb fractures with follow-up by trust (2022/23)

Min

18.4 %

1st quartile

56.9 %

Median

66.8 %

3rd quartile

77.8 %

Max

98.2 %

Min

25.9 %

1st quartile

73.4 %

Median

83.5 %

3rd quartile

90.5 %

Max

100 %

Min

5.6 %

1st quartile

47.6 %

Median

61.6 %

3rd quartile

83 %

Max

97.4 %

Lower limb fractures with follow-up by trust (2022/23)

Min

20.9 %

1st quartile

72.9 %

Median

84.8 %

3rd quartile

90.2 %

Max

100 %

Min

11.7 %

1st quartile

31.8 %

Median

45.9 %

3rd quartile

56.7 %

Max

100 %

Forearm fractures manipulated in theatre by trust (2022/23)

Min

0.2 %

1st quartile

1.7 %

Median

3.5 %

3rd quartile

5.5 %

Max

19.8 %

Elbow fractures manipulated in theatre by trust (2022/23)

Min

0.3 %

1st quartile

0.8 %

Median

1.4 %

3rd quartile

2.1 %

Max

8.8 %

Tibia/Fibula fractures manipulated in theatre by trust (2022/23)

Min

0.4 %

1st quartile

1.6 %

Median

2.7 %

3rd quartile

4.1 %

Max

9.7 %

Recreating the GIRFT metric

These proportions are slightly lower than seen in the GIRFT study. It is not clear exactly which fracture types and which manipulations were included within that study.

We have excluded open fractures and only included manipulations without internal or external fixation, which may explain the discrepancy in the results.

Appendix 1

Fracture codes

Manipulation in emergency department

A&E treatment code: 10- Reduction

Manipulation in theatre

OPCS codes:

W262 Manipulation of fracture of bone NEC W268 Other specified W269 Unspecified W663 Primary manipulative closed reduction of fracture dislocation of joint NEC